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Pediatrics, Appendicitis

Author: Kara E Hennelly, MD, Fellow, Department of Pediatric Emergency Medicine, Children's Hospital Boston
Coauthor(s): Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Contributor Information and Disclosures

Updated: Feb 12, 2009

Introduction

Background

Appendicitis, the most common pediatric surgical emergency, is caused by inflammation of the vermiform appendix. Four of 1,000 children younger than age 14 years will be diagnosed with appendicitis. Common symptoms of appendicitis include abdominal pain, fever, and vomiting. The diagnosis of appendicitis can be difficult in children because the classic symptoms are often not present.

A delay in the diagnosis of appendicitis is associated with rupture and associated complications, especially in young children. Improvements in rupture rates have been made with advanced radiologic imaging. Appendicitis is a clinical diagnosis with imaging used to confirm equivocal cases.

Pathophysiology

The appendix arises from the inferior tip of the cecum as a long, thin diverticulum.  For most children, the cecum is located in the right lower quadrant. The base of the appendix is fixed to the cecum. However, the tip can be located in the pelvis, retrocecum, or extraperitoneum.  

The exact function of the appendix is unknown. It is a highly lymphatic structure, suggesting an immunologic role. 

Appendicitis results from a luminal obstruction. This obstruction can be caused by fecaliths, lymphoid hyperplasia, foreign bodies, or parasites. Children and adults have also developed appendicitis following severe blunt abdominal trauma.

Once the appendiceal lumen is blocked, the appendiceal mucosa becomes edematous. A cycle begins where intraluminal pressure increases, inflammation ensues, and exudate drains from the appendix. Fecal bacterial overgrowth occurs within the obstructed lumen, thereby enhancing the inflammatory response and further increasing the intraluminal pressure. The increase in intraluminal pressure leads to a dull generalized discomfort. The patient experiences increased focal pain as the transmural inflammation extends to the peritoneum. 

With delayed diagnosis of appendicitis, the obstruction progresses, the wall of the appendix stretches due to the further rise in intraluminal pressure, and perforation occurs. When the inflammatory fluid and bacterial contents are released into the abdominal cavity, peritonitis develops. Concomitantly, the patient complains of more intense and generalized abdominal pain.

In adults and adolescents, the omentum can wall off the inflamed or perforated appendix, causing a focal abscess. In the younger child, the omentum is less well developed and less likely to wall off a perforation, making peritonitis more likely.

Frequency

United States

  • Appendicitis has an incidence of 70,000 pediatric cases per year in the United States.
  • Appendicitis has an incidence of 1-2 cases per 10,000 children per year between birth and age 4 years.
  • The incidence increases to 25 cases per 10,000 children per year between 10 and 17 years of age. 

Mortality/Morbidity

  • The rate of appendiceal perforation is 80-100% for children younger than 3 years compared to less than 10-20% of children aged 10-17 years. 
  • The mortality rate for children with appendicitis ranges from 0.1-1%.
  • Delay in diagnosis increases perforation rate.

Race

The role of race, ethnicity, health insurance, education, access to health care, and economic status on the development and treatment of appendicitis are widely debated. Cogent arguments have been made on both sides for and against the significance of each socioeconomic or racial condition.

Sex

  • The male-to-female ratio of appendicitis is approximately 1.4:1.

Age

Appendicitis occurs in all age groups. The diagnosis of appendicitis in a younger child is more difficult and often the condition is more advanced. 

  • Appendicitis affects patients in the second decade of life most frequently (aged 10-19 y), at a rate of 23.3 cases per 10,000 per year.
  • The rate of appendicitis in children younger than age 4 years is 1-2 per 10,000 per year. Children younger than 4 years almost universally present after perforation. 
  • Appendicitis is extremely rare in the neonate, and the diagnosis in this age group is typically made after perforation.

Clinical

History

Understanding the typical clinical manifestations of appendicitis is essential in order to make an early and accurate diagnosis prior to perforation. The classic history of anorexia and periumbilical pain, followed by right lower quadrant (RLQ) pain, fever, and vomiting, is observed in fewer than 60% of patients.1 The clinician is more likely to make the diagnosis by maintaining a high degree of suspicion and a broad differential diagnosis, and looking for the atypical case rather than the classic appendicitis.   

Vomiting, RLQ pain, focal tenderness, and guarding are significantly associated with appendicitis.

  • The initial symptom is poorly defined periumbilical pain, often associated with anorexia.
  • After a few hours, the pain migrates to the RLQ due to inflammation of the parietal peritoneum.
    • This pain is more intense, continuous, and more localized than the initial pain.
    • This shift of pain rarely occurs in other abdominal conditions.
  • Most children with appendicitis either are afebrile or have a low-grade fever. High fever is not a common presenting feature unless perforation has occurred.
  • Becker et al found that 44% of patients diagnosed with appendicitis presented with 6 or more atypical features.2
    • Examples of atypical features include absence of anorexia, nausea, migration of pain, RLQ pain, and pyrexia. 
    • Abrupt onset of pain, diarrhea, and pain longer than 48 hours are further examples of atypical features of appendicitis. 

Physical

Children vary in their ability to cooperate with the physical examination. It is important to tailor the physical examination with respect to the child's age and developmental stage. It is also important to exclude extra-abdominal causes of abdominal pain, such as urinary tract infection (UTI) or pneumonia. 

  • In early appendicitis, children may have focal tenderness in the RLQ without significant guarding or peritoneal signs. 
  • Observation of the child's interaction and gait prior to the examination can be extremely helpful. If able to stand, asking a child to hop is helpful in assessing for peritoneal irritation. If the child is unwilling to stand, shaking the bed or pelvis can also evaluate for peritoneal signs. 
  • A child with advanced appendicitis typically prefers to lie still due to peritoneal irritation.
  • The child may have localized guarding or rebound tenderness.
  • Typically, maximal tenderness can be found at McBurney's point, which is halfway between the umbilicus and the anterior superior iliac spine in the RLQ.
  • On examination, bowel sounds may be decreased.
  • Rovsing sign is pain in the RLQ in response to palpation of the left lower quadrant (LLQ), suggestive of peritoneal irritation.
  • The psoas sign is elicited by placing the child on the left side and hyperextending the right hip.
  • The obturator sign is determined by internal rotation of the flexed right thigh. Pain on movement may be caused by an inflammatory mass overlying the psoas muscle.
  • A mass may be palpable in the RLQ if the appendix is perforated.
  • An external genitourinary (GU) examination is helpful to rule out testicular or scrotal tenderness in males and hematocolpos in pubertal females. 
  • A rectal examination should be performed last and may reveal impacted stool, right-sided tenderness, or a mass. Be sure to perform a rectal examination (inspection, palpation, and digital examination) in children who have any abdominal tenderness, a history of constipation, a history of rectal bleeding, trauma, or suspected physical abuse. A retrocecal appendix may cause exquisite tenderness on rectal examination.
  • A pelvic examination should be considered in sexually active females to evaluate for tenderness (adnexal and/or cervical motion tenderness), masses, bleeding, or discharge.

Causes

Appendicitis results from a luminal obstruction. This obstruction can be caused by fecaliths, lymphoid hyperplasia, foreign bodies, or parasites. Children and adults have also developed appendicitis following severe blunt abdominal trauma.

More on Pediatrics, Appendicitis

Overview: Pediatrics, Appendicitis
Differential Diagnoses & Workup: Pediatrics, Appendicitis
Treatment & Medication: Pediatrics, Appendicitis
Follow-up: Pediatrics, Appendicitis
References
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Further Reading

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Keywords

appendicitis, appendicitis in children, acute inflammation of the appendix, abdominal pain, appendix, acute appendicitis, appendiceal inflammation, peritonitis

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Contributor Information and Disclosures

Author

Kara E Hennelly, MD, Fellow, Department of Pediatric Emergency Medicine, Children's Hospital Boston
Kara E Hennelly, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Coauthor(s)

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

Medical Editor

Kirsten A Bechtel, MD, Associate Professor of Pediatrics, Department of Pediatrics, Yale University School of Medicine; Consulting Staff, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital
Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Wayne Wolfram, MD, MPH, Clinical Associate Professor, Departments of Pediatrics, Children's Hospital and University of Cincinnati
Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD, Assistant Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston
Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research
Disclosure: Nothing to disclose.

 
 
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